Anorexia nervosa is an eating disorder that affects both women (~0.9% lifetime prevalence) and men (~0.3% lifetime prevalence) in the United States.1 The Eating Disorders Coalition (EDC) indicates that at least 30 million Americans suffer from an eating disorder at some point in their lifetime, and that every 62 minutes at least one person dies as a direct result of an eating disorder.2
Anorexia is a serious mental health condition with an alarmingly high mortality rate—only second behind that associated with opioid addiction.2 Anorexia can additionally place stress on families and friends as they watch their loved one’s health deteriorate while perhaps struggling to get them the help they need. People with eating disorders may be opposed to any treatment, because weight loss and/or maintaining a significantly low weight can begin to take precedence over other important aspects of one’s life.3,5 At a fundamental level, anorexia is semi-starvation, sometimes combined with purging behaviors and/or other methods to reduce appetite and facilitate weight loss.4
Per the American Psychiatric Association, key diagnostic features of anorexia nervosa include:4
- Persistent restriction of caloric intake relative to normal requirements.
- Strong fear of weight gain or becoming fat; or behavior that prevents weight gain.
- Disturbances in self-perceived weight or distorted body image; lack of recognition of the seriousness of the current, underweight state.
Subtypes include the restricting type and a binge-eating/purging type. With the former, weight loss is accomplished through fasting, dieting, or excessive exercise behavior, while the binge/purging type (a separate diagnosis from bulimia) may include recurring episodes of vomiting as well as laxative, diuretic, and/or enema misuse.4
Eating Disorders: A Complex Picture
The National Institute of Mental Health (NIMH) website indicates that the median age of onset for anorexia nervosa is 18 years old. Based on survey information, for adults 18 and older in the U.S., the lifetime treatment rate for anorexia is approximately 33.8%—a discouraging figure that suggests that a substantial amount (roughly two-thirds) of people do not get the help they need.1
In 2003, the National Center on Addiction and Substance Abuse (CASA) reported that as many as 50% of those with an eating disorder also abuse substances (alcohol or illicit drugs)—a rate roughly five times greater than that seen in the general population.6 Conversely, as many as 35% of people with substance abuse or dependence issues were found to also have eating disorders. This overlap underscores the need for proper support and treatment protocols that will allow individuals with these co-occurring conditions to reclaim their lives.
Co-Occurring Anorexia and Addiction
In 2011, the Substance Abuse and Mental Health Services Administration (SAMHSA) published an advisory regarding co-occurring substance abuse and eating disorders. The advisory highlights the fact that eating disorders (EDs) frequently co-occur with substance use disorders (SUDs), and discusses some of the challenges of integrated treatment for both. The advisory cites several studies to support the relationship between EDs and SUDs, including one that found that as eating disorder intensity increased, the number of different substances being abused increased as well.7
It is possible that some people with eating disorders drink or use drugs in an attempt to self-medicate negative feelings/emotions that accompany the eating disorder or, even, after treatment for the eating disorder, should the same sources of stress and emotional distress that led to the eating disorder still remain.6,7
Helping a Loved One with Anorexia
It is very difficult for family and friends to watch a loved one struggle with what could ultimately result in severe deterioration of their health and even death. What begins as abnormally restrictive food intake could, left untreated, progress to outright starvation. The weight loss becomes substantial, their physical appearance changes, and they are clearly quite ill. They may deny and argue when faced when the assertion that they are too thin. Though it may often be challenging to encourage someone into treatment (and treatment outcomes may be somewhat improved when an individual willingly embraces their recovery), the end result of such treatment can save lives.3
Treatment of Anorexia and Addiction
Historically, treatment programs for substance use disorders have not always been equipped to manage co-occurring eating disorders and vice versa. As a result, though a patient may have received appropriate treatment for one disorder, they might not have for both.6 However, as awareness of this common comorbidity has risen, and as effective, integrated recovery strategies have been developed, the treatment landscape has been changing.
Anorexia, with its association with suicidal thoughts and other deleterious health effects, can be life-threatening. Similarly, the cumulative health risks of addiction are to be taken very seriously.
Acute treatment for severe cases of anorexia often focuses on refeeding to stabilize a patient and allow for better focus on continued recovery efforts.3,6 Longer-term management of co-occurring eating disorder and substance use disorder may involve a multi-disciplinary team and the administration of several psychosocial, behavioral, and pharmacological interventions.3 Given the complexities of such a dual diagnosis, residential treatment is an appropriate treatment setting for people with these co-occurring disorders.8
Treatment for anorexia and addiction commonly involves a multidisciplinary treatment strategy, which may utilize several different therapeutic techniques, such as:1,6,7
Individual psychotherapy—including talk therapy and other behavioral therapeutic approaches. Individual psychotherapy allows those in recovery to speak confidentially with their therapist and talk through issues as well as how to succeed once they are discharged.
Cognitive Behavioral Therapy (CBT)—helps a patient better understand the interconnectedness of thoughts (e.g., distorted body image, etc.), feelings, and behaviors surrounding maladaptive patterns of eating and/or substance use, to make healthier choices moving forward. A therapist trained in CBT can work with the individual by helping them identify negative thought patterns, work through their roots, and give the individual new tools to manage their illness.
Medications—when appropriate, such as antidepressants for co-occurring depression or anxiety, as well as medication-assisted treatment medications for substance use disorders such as alcohol and opioid use disorder.
Nutrition counseling—involving dietitians and other health care professionals to help change unhealthy dietary patterns and maladaptive beliefs about food. Nutrition counseling allows them to develop healthy eating habits that can sustain them post-treatment. Healthier food planning and weight monitoring duties are sometimes shared with other members of the treatment team (e.g., mental health therapists) as well as family members.
Family therapy—can be immensely beneficial as it empowers family members to help ensure healthy eating and otherwise support recovery. Family therapy also can be very effective in repairing relationships that have been damaged by the eating disorder or ongoing addiction. Under direction from a therapist, the client can talk with their family, and together, they may identify environmental triggers or activities that could invoke previous habits that may endanger their health.
An emphasis on relapse prevention—to help those in recovery from eating disorders and substance abuse make healthier decisions and avoid stressors, triggers, or situations where drinking, drugs, or food have been maladaptively used in the past.
Self-help approaches—which may include structured audiovisual materials or manuals based on the principles of cognitive-behavioral therapy or peer-led support groups such as Overeaters Anonymous (OA) and Eating Disorders Anonymous (EDA). Support groups can be an excellent way for those with eating disorders to connect with peers on a different level than in other types of relationships. These groups allow participants to learn from others who have been in similar situations. They provide an invaluable source of support for those in recovery from both anorexia and substance abuse.
Help Is Available
People with both a substance use disorder and anorexia may benefit from an integrated, multi-disciplinary treatment strategy.6 Despite the strong grip that anorexia and addiction can have on a person, there is hope for full recovery. Given the high incidence of associated medical issues and the potential for significant psychiatric instability, people with co-occurring SUD and ED issues may particularly benefit from treatment in an inpatient or residential environment, where their safety can be the top priority.
- National Institute of Mental Health. (2017). Eating Disorders.
- Eating Disorder Coalition. (2016). Facts About Eating Disorders: What the Research Shows.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- Diagnostic and statistical manual of mental disorders: DSM-5.(5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
- National Alliance on Mental Illness. (n.d.). Eating Disorders—Overview.
- Center on Addiction. (2003). Food for Thought: Substance Abuse and Eating Disorders.
- Substance Abuse and Mental Health Services Administration. (2011). SAMHSA Advisory—Clients with Substance Use and Eating Disorders.
- Michael, ML, Juarascio, A. (2019). Differences in eating disorder symptoms and affect regulation for residential eating disorder patients with problematic substance use. Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity. 2019 Oct 14 [Epub ahead of print].